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158-159 WASHINGTON ST - BUILDING INSPECTION LR&&W SIONAL DESIGN SERVICES:. Registered Architect: 2pi1/fiG O LA/�'JA�eE Seal and Signature ,� �aeR�efl�� GLoivE �m�ev 4R�y�r�� z rHOF Ga. -527-9090 Fax 'do3-677- PIP/rYd Profassl4n>t; 9lnears ( + uw+al atesa if r�essarf!and attxh se avPbn) Name: :,JEiF Nf4id 2oG,i--/ seat and S Address:_. / 9a7-U1y711 6 PoeTs/�1od7" /✓�/ a3eoi or +P C'SG a J FFREY S. �".. AWROCKI + STRUCTURAL No.34166 Telephone: :�503- 4 3�5- Fax 8 �03 43/-cam// 'spy AF0 s7EREO�e FSSIOsi t EMD A!a ,of Responsibility .57'eaCTUeitL EGir✓E��2 /lE�ato ' Name: Seal and.Signature' . Address: Telephone: Fax Area of Responsibility: Name: Seat and Signature Address: Telephone: Fax: Area of responsibility: Application for Permit to: auc,y Location Permit Granted 6 'D Approv Inspector of Buildings i 6.0 PROFESSIONAL CONSTRUCTION SERVICM 6.1 General Contractor D�EfH�E <oivs7�ucTia.✓ �aei� Address: T6 oei✓E /✓W 0 32Zo Telephone: 6 13 - 527-90 90 Fax: Responsible in Charge of Construction: Jhsa/5/ C. ,�LfJ/S 7.0 CONSTRUCTION DOCUMENTS -to be prepared by applicant Item as Applicable 7.1 Plans (Note 1 this page) Submitted Incomplete Not Required 7.1.1 Architectural 7.1.2 Foundation 7.1.3 Structural v. 7.1.4 Fire Suppression 7.1.5 Fire Alarm t� 7.1.6 WAC 7.1.7 Electrical 7.2 Specifications 7.3 Structural Peer Review 7.4 Structural Tests & Inspections Program 7.5 Fire Protection Narrative Report 7.6 Existing Building Survey 7.7 Workers Compensation Insurance 7.8 Other Documents (Specify) (Energy Narratives, etc.) Note 1 Areas of Design or Construction for which Plans are not complete at the time of this application must be identified herein. Work so identified must not be commenced until this application has been amended and proposed construction has been approved by the Department of Public Safety District Building Inspector having Jurisdiction. 8.0 COMPLETE THIS SECTION FOR NEW CONSTRUCTION ONLY For Existing Buildings Proceed to Section 9.0 Number of Stories above 1 Number of stories Below 0 Grade Grade Story Height /s /¢ Floor Area Per Floor /O,H94', /O'69� g Z1°p3Fp Total Building Height 49 Total Building Area Above ¢Z� Asa sr above Grade /. Grade Total Building depth below Q Total Building Area Below Grade Grade Brief Description of Proposed Work: PAFelolf Irv/Goi../c P.�I� .eon Cc.,/S7B�1 ✓EJBSU�ff/C� Be�S o<35?edG� W2 USE GROUP AND CONSTRUCTION CLASSIFICATION (Now Construction Only); USE t3ROU USE GROUP SUB-CATEGORY CONSTRUCTION (� as applicable (,,as appiicati!o. CLASSIFICATION A . Assembly a i � ' A-2: �. A 3`, A=4' 1A 8 Business 1 B E Educational 2A F Factory F-1 F-2 2B H High Hazard H-1 H-2 H-3 H-4 2C Institutional` 1-1 1-2 1-3 3A M Mercantile `. ✓ 38 R Residential_ t/ R-1 LR-2 ✓ R-3 4 S Storage l� S-1 ✓ 5A . U Utility 5B Mx Mixed Use Specify: Specify: Sp Special Use 9.0 CONSTRUCTION COSTS (See 780 CMR Appendix L) Total Construction Cost Building Permit Pee Check Number (1) =(1) x $0.001 l�at 1000 f/90, ad oS9�o6 10.0 AUTHORIZATION OF STATE AGENCY FOR AGENT TO APPLY FOR BUILDING PERMIT (when applicable) i, on behalf of the authorizes State Agency or Authority, hereby authorize, to lap* for the building permit for project number, Signature Date 11.0 SIGNATURE OF BUILDING PERMIT APPLICANT Ji9sa�/ C. �L,�tiS_, a��cHdE r��srQ�GTivn� CO2P Name n ure Date 12. Cartiflcate of Occupancy required on completion of project? Yes No Inspector's Notes: ACORa CERTIFICATE OF LIABILITY INSURANCE 02/19/zoos PRODUCER (603)224-2562 FAX (603)224-8012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Rai Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 139 Loudon Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 511 Concord, NB 03302-0511 INSURERS AFFORDING COVERAGE NAIC# INSURED Opechee Construction Corporation INSURERA: Acadia Insurance Company 31325 11 Corporate Drive INSURER B: Belmont, NB 03220 INSURERC'. INSURER D. NSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR kDD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE IMM/DDYY1 DATE IMMIODNY' LIMITS GENERAL LIABILITY CPA0120746-14 08/01/2007 08/01/2008 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAM AGE TO RENTEDrri $ 250,000 CLAIMS MADE T OCCUR VIED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- JECT X LOC AUTOMOBILE LIABILITY CAA0120747-13 08/01/2007 08/01/2008 COMBINED SINGLE LIMIT X ANYAUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY IS A SCHEDULED AUTOS (Per person) X HIREDAUTOS BODILY INJURY X NON OWNEDAUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY CUA0120749-14 08/01/2007 08/01/2008 EACH OCCURRENCE $ 10,000,000 X OCCUR El CLAIMS MADE AGGREGATE 5 10,000,000 A $ DEDUCTIBLE $ X RETENTION $ C I I S WORKERS COMPENSATION AND WCA0155993-13 08/01/2007 09/01/2008 X I w0Cg SUTj OER TH- EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 500,000 A ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? EL.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Washington At Derby, 155 Washington St., 31 Front St. and 26 New Derby St. Salem, MA 01970. ashington At Derby, LLC & Bank of America are additional insureds with respect to general liability d umbrella liability. _ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Washington At Derby, LLC BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 17 Ivaloo, Suite 100 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Somerville, MA 02143 AUTHORIZED REPRESENTATIVE Danielle Ma oon/DJM �"`;"� ff�1QEp,, Ov�'l ACORD 25(2001108) ©ACORD CORPORATION 1988 i CITY OF S.ULEiNI, 1AXSSACHUSETTS " BUILDING DEP1RTN&NT : 130 WASHINGTON STREET,3'O FLOOR ` TEL (978) 745-9595 FAX(978)740-9846 KIJBERL.EY DRISCOLL MAYOR THOMAS ST.PmRRa DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%MSSIONER APPLICATION FOR THE CONSTRUCTION, REPA K RENOVAT10N, CHANGE INFUSE OR OCCUPANCY.OR DEAIounoN OF ANY BUILDING OR STRUCTURE This Seddon,for Omclal Use Only . .. i 134'"Parmit Project. SITE G I�►I Oahe -`/j/ ; 1 Building Inspectors 3ignehirp p' Eatlnlett#Project Dates: Start End: Convnents: 1.0 SITE INFORMATION 15q- (/�ww/w Location Name: �t✓NTOc%Y v51 e177 Building: ,L0 ' Prop"Address: .5 e2r1 24 /✓mow oE,eBd sreee-r /SS Cf/AS/////6TN STeEET Assessors MapiBlock 3¢ LoUParcet ¢Z3 SGZS ¢2cro �} 2.Q�4WNERSHI[+IWORMATION O l N 2.1 Owns►of Land N Name: WX7_c111Yer01V fIT 42E2,6y, LZG J Address: yo ,EGG LLG .� /7 /Vf1L00, SU/TC/Op SonlB2!//GGE //7A 00/¢3 Telephone: G/7- lo25`— 78/7 2.2 Owner or lessee of building or sbvchue 0Name: .SfI/77E' Address: Telephone: 3.0 AGENCY OR AUTHORITY AUTHORIZING CONSTRUCTION Agency Name: ;et Address: Agency Project Number.Project Manager Name: 'a'j s �r ✓/�e (�miv�rz�vzui�cll� �y.�l�i�aluc�tudelld �.� BOARD OF BUILDING REGULATIONS ' a License: CONSTRUCTION SUPERVISOR Number: CS 071623 *• Birthdate; 04/20/1963 111 Expires: 04/20/2008 Tr.no: 26241 1 Restricted: 00 SEYMOUR Z HOWES 66 LITHFIELD RD G-- LONDONDERRY, NH 03053 Commissioner